What is "posterior" surgery for lumbar disc herniation?

The term "posterior" surgery refers to a surgical approach that begins with an incision in the back and proceeds layer by layer. The "posterior" approach is the most common surgical procedure used to treat lumbar disc herniation. A typical procedure is as follows.

(1) The patient is placed in a lateral position with the affected limb on top, or in a prone or modified prone position to avoid chest and abdominal compression.

(2) A median incision is made in the back, extending to one lumbar vertebra above and one below the diseased intervertebral space, generally about 8 to 12 cm in length.

(3) The skin, subcutaneous tissues, and supraspinous ligament are incised, and soft tissues are peeled away in the direction of the vertebral plate.

Generally, it is necessary to push the stripped muscle to the midline of the lesser joints,*** and the three spinous processes need to be exposed. If a total laminectomy is performed, the muscles on both sides of the spinous processes should be separated.

(4) The muscles are retracted using a special hook or spreader to fully expose the laminae and spinous processes.

(5) Enter the spinal canal and remove the ligamentum flavum. The nerve root is in the spinal canal, and there are several methods of entering the spinal canal, including total laminectomy, hemilaminectomy, window entry, and intervertebral space entry, which should be selected according to the needs of the disease. The ligamentum flavum is in the posterior part of the spinal canal, and complete removal of the ligamentum flavum as far as possible is the only real access to the spinal canal.

(6) After entering the spinal canal, protruding discs and compressed nerve roots can be found in the diseased intervertebral space. The nerve root is made to fully expose the herniated disc under direct vision or under the protection of a nerve separator. If the annulus fibrosus is intact, a small sharp knife is used to make a cruciate incision in the bulge. The nucleus pulposus is removed with a nucellar forceps from shallow to deep. Nucleus pulposus should be removed as thoroughly as possible, so as to reduce the chance of postoperative recurrence.

(7) After removing the nucleus pulposus, stop the bleeding strictly, flush the wound, put the drainage tube and suture layer by layer.

The most important step in posterior surgery is the intravertebral canal operation, which requires gentle movements to minimize bleeding. This keeps the field clear and reduces the chance of adhesion formation.

In addition, the relationship between the nerve root and the herniated disc should be carefully observed after entering the spinal canal to protect the nerve root. For more complex clinical presentations with symptoms of multiple nerve root involvement, intraoperative exploration is also needed to rule out double herniation.